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as an artefact           of collection process or technique
Decreased excretion (frequent cause)
o Renal diseases: Acute/chronic renal failure, renal anomaly
o Adrenal mineralocorticoid deficiency
o Acidosis Eg. Diabetic ketoacidosis, lactic acidosis
Increased production (Most often if in association with renal dysfunction)
o Extensive trauma, rhabdomyolysis (crush injury, convulsion, infection), lysis syndrome, burns
Exogenous source
o Iatrogenic potassium administration (oral, IV)
o Increased ingestion
o Massive transfusion
o Eg. NSAID, trimethoprim, heparin, chemotherapy, K-sparing diuretic, ACE inhibitor, beta blockers, succinylcholine, digoxin, mannitol
History and examination:
Look for possible causes (see above)
can be initially asymptomatic or can presents with severe symptoms/signs:
Respiratory depression
Palpitations, arrhythmia, cardiac arrest
flaccid paralysis
Confirm that potassium in IV fluids and oral potassium supplements are stopped
Assess the patient’s medication list – stop drugs that increase potassium or reduce its excretion
Investigation and monitoring:
Note: Patients with moderateneed continuous cardiac monitoring and IV access

Level of potassium should be confirmed with a second sample
If patient has renal dysfunction (renal failure or other renal disease), assume potassium level correct until proven otherwise
Acute increase of potassium is associated with higher risk of arrhythmia
Do an ECG to identify conduction disturbance:
Peaked T wave (early)
Prolonged PR, flattening of P wave, widening of QRS (increased risk of arrhythmia)
Absence of P wave, sine wave (fusion of QRS and T wave)
Ventricular arrhythmia, asystole
Note: A normal ECG does not exclude risk for arrhythmia, as life threatening arrhythmia can occur without warning

Complete investigations and consider ca
Urea, creatinine and electrolytes
Venous blood gas
+/- Urine analysis and urinary electrolytes
Consider other investigations depending on cause:
Cortisol, aldosterone and hormonal precursor levels (particularly if
Level of digoxin (if relevant)
– Treatment: (flowchart)
If pulseless arrhythmia, see Resuscitation

***Stop any source of potassium intake – IV fluid, parenteral alimentation, dietary supplement (including NGT feeding) and any potassium-sparing medication

– K+ >/L or at risk of increasing and/or
– Patient symptomatic and/or
– ECG disturbance:

Calcium IV
Salbutamol neb
Insulin/glucose IV
Bicarbonate IV if metabolic acidosis
Urgent if unstable
Rapid if stable but symptomatic or abnormal ECG
Consider if asymptomatic but se
(Polystyrene sulfonate) PR (if dialysis unavailable)
Consider hydrocortisone 1-2 mg/kg IV if suspicion of adrenal insufficiency

– K+ 6-7
– Patient asymptomatic
– Normal ECG

Salbutamol neb
Insulin/glucose IV
(Polystyrene sulfonate) PR or oral
Bicarbonate IV if metabolic acidosis

– K+ >5.5

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